Somesha Ayobo couldn't breathe. Morbidly obese and 35 weeks pregnant, she tried to treat herself with cough syrup, but over four days, her symptoms grew worse. On the morning of June 24, her roommate called an ambulance.
For the sick and injured, geography is destiny in at least one concrete way: Emergency responders often transport a patient to the closest hospital. For Ayobo, who lived in the Wheeler Terrace Apartments — a 115-unit complex in Southeast Washington where gunfire can sometimes be heard from nearby Oxon Run Park — that was United Medical Center. She arrived at the District-owned hospital just after 12:30 p.m.
For the next six hours, she languished in the emergency room while doctors and nurses took different and sometimes confused tacks in their efforts to care for her and her unborn child. By nightfall, Ayobo was dead. Her baby — a girl, Phoenix, born by emergency Caesarean section — would die four days later.
Their deaths would have much broader consequences for women in the poor and predominantly African American neighborhoods east of the Anacostia River, where infant-mortality rates are the city's highest.
Errors in Ayobo's treatment identified by D.C. regulators precipitated the closure of UMC's obstetrics ward in August, a decision that left a broad section of the nation's capital without a hospital for women to give birth or receive prenatal care.
D.C. Department of Health Director LaQuandra S. Nesbitt has repeatedly refused to disclose details of the cases that led her to shutter UMC's nursery and delivery rooms. The Washington Post identified Ayobo and her daughter based on information in Health Department investigative files obtained through a public-records request and interviews with Ayobo's relatives and friends.
Her story is in many ways emblematic of problems and challenges at UMC, a hospital whose mission to serve some of the District's poorest and sickest people has been hampered by decades of mismanagement and changing political winds.
Ayobo, who weighed 520 pounds and had been diagnosed with a potentially fatal blood-pressure condition associated with high-risk pregnancies, lived in a part of the city where babies die at more than twice the rate of the U.S. as a whole and nearly 10 times the rate of those in affluent northwest Washington.
She was seen and discharged by at least one other Washington-area hospital before winding up at UMC. In the days before her death, her roommate said, she also repeatedly called her managed-care organization but was told she didn't need to see a doctor.
In the end, she was driven by ambulance to D.C.'s only public hospital, just a half-mile from her apartment. Once there, according to Health Department records, she experienced repeated lapses in treatment, including unexplained delays, failures to properly monitor her or her baby's condition and confusion among the medical staff that led to Ayobo's being wheeled into the wrong operating room after her heart stopped beating.
Ilita Peterson, Ayobo's cousin and one of her closest relatives, said she also gave birth at UMC and has followed periodic announcements of improvements there: new doctors, new executives or refurbished facilities. After Ayobo's death, she has little faith that change is possible.
"You hear about the renovations, and you think it's better," Peterson said. "It's still the hospital from hell."
Ayobo came to UMC as a last resort.
At 35, the native of Landover, Md., had already been through one high-risk pregnancy, giving birth to a son who lived in North Carolina with his father, according to friends and relatives. Ayobo's mother and brother are dead.
When she learned she was pregnant again, her excitement was tempered by her knowledge of the complications that could ensue from her size. But she was determined to live more healthfully after the baby was born, her family said, and had talked about dieting and bariatric surgery.
Her sanguine mood was captured in the name she chose for the baby girl she carried. "She was planning to start a new life," Peterson said.
As her pregnancy progressed, reality intruded on those plans. Early in the summer, she was admitted to Holy Cross Hospital in Silver Spring, Md., and diagnosed with preeclampsia, a sometimes deadly blood-pressure condition in pregnant women, her relatives said.
Elizabeth Dooley, director of marketing at Holy Cross Health, said the hospital could not comment because of patient-privacy laws.
Ayobo was discharged from Holy Cross, and about a month later, her breathing problems started, said Talia Chestnut, her roommate at Wheeler Terrace. Chestnut said that over the course of four days, Ayobo repeatedly called her managed-care health provider, Kaiser Permanente, but was told that she did not need to see a doctor and could treat herself with pregnancy-friendly cough syrup.
A spokesman for Kaiser Permanente declined to comment on Ayobo's case.
"We would like to express our sympathy to this member's loved ones. However, because of patient privacy laws, we cannot provide information about any member's care," Kaiser spokesman Scott Lusk said in a written statement. "We can state that our care teams are committed to ensuring all our pregnant members receive excellent care."
Chestnut said Ayobo tried cough syrup and Chestnut's asthma nebulizer. Her symptoms worsened.
"I knew something was wrong," Chestnut said. "She kept coughing, and every time you turned around, she was short of breath."
Finally, Chestnut said, she persuaded Ayobo to visit a hospital and called an ambulance.
After Ayobo arrived at UMC, the medical staff quickly confirmed that her breathing trouble was severe, according to Health Department records. The amount of oxygen in her blood was just 61 percent of normal levels: She and her baby were effectively suffocating.
Ayobo, whom the records do not name but refer to as "Patient #90," was given oxygen that restored her blood to normal levels. But the course of events over the next six hours is only partially illuminated by the investigative report on Ayobo's case, which cites shortcomings by the obstetrics and emergency department staff.
At 12:37 p.m., a doctor ordered that nurses check her fetus's heartbeat, but that assessment did not take place for more than two hours, and it was performed only when Ayobo received an ultrasound exam at 2:53 p.m.
The inspection states that medical staff said they tried to find a fetal heartbeat for about 45 minutes but couldn't because of Ayobo's size.
At 1:36 p.m., according to the report, an ER doctor consulted an obstetrician. At 1:54, the obstetrician came to the emergency department to see Ayobo and at some point "recommended that the patient be transferred to a higher level of care" because of the "high risk factors involved," according to the report.
Yet it was not until 6 p.m. that an emergency team arrived to transport Ayobo to another facility, the report states. Before she could leave the hospital, her heart stopped beating, and she was rushed to the main operating room in a last-ditch effort to save her baby.
Once there, the medical staff realized they did not have appropriate equipment for neonatal care, according to the report. They again moved Ayobo, this time to the labor and delivery unit's operating room, on a different floor.
Warren Lewis, Ayobo's cousin, said he arrived at UMC as the sun was going down and felt a sense of the surreal as he wandered a nearly empty labor and delivery unit looking for someone to explain what had happened. "The whole vibe was really weird," he recalled.
Ayobo was dead. Her death certificate, reviewed by The Post, lists four possible causes, a catalogue of overlapping debilities that in some combination killed her: cardiopulmonary arrest, hypoxia, pulmonary edema and morbid obesity.
Phoenix lay with tubes snaking from her tiny body in the hospital's neonatal intensive care unit. She was transferred that night to Children's National Medical Center in Northwest Washington.
"With the loss of Mandy, it was already a lot," Lewis said, using Ayobo's nickname. "But we were hoping the daughter was going to live."
Former employees of the UMC obstetrics ward defended the hospital's handling of Ayobo, saying she and her baby required more advanced care than what they were capable of providing in their unit, which delivered about 30 babies per month and was not intended to offer complex treatments for newborns with extreme health problems.
"This mother should never have come through the door," said Dr. Marilyn McPherson-Corder, the hospital's former head of pediatrics, who worked in the nursery before it closed. She said emergency room physicians should not have admitted Ayobo and should have instructed paramedics to take her directly to another hospital.
Dr. Mehdi Sattarian, who was head of the emergency department when Ayobo was seen, declined to comment on the specifics of the case. Asked whether the hospital should not have admitted Ayobo, he pointed to a federal law prohibiting hospitals that participate in Medicare from refusing to treat people based on ability to pay.
That statute, the Emergency Medical and Labor Treatment Act, says that if a patient has a medical emergency, the hospital "must provide treatment to stabilize the medical condition, or appropriately transfer the individual to another hospital."
McPherson-Corder said the obstetrics ward's capabilities had also been hampered because of inattention from hospital managers, who she alleged had not sufficiently staffed the unit.
"This is like a MASH unit. This is like, third-world," she said. "The excuse was, y'all are not busy. Well, it only takes one incident."
Betty Holmon, a registered nurse who worked in the maternity ward until it closed and had been employed at UMC for more than three decades, said nurses in the obstetrics ward were regularly diverted to duties in other departments when the unit wasn't busy, a practice that left the ward understaffed for emergencies.
"They were pulling people away," she said.
Since 2016, UMC has been run by Veritas, a Washington consulting firm that has collected nearly $6 million in fees through a contract with the D.C. government.
The company's executive chairman, Corbett Price, was a major political donor to Mayor Muriel E. Bowser (D) and has a record of "turnaround" projects that involved slashing spending at troubled hospitals.
The D.C. Council voted in November not to extend the Veritas contract after a series of Post stories documenting problems at UMC — Veritas delivered roughly a tenth of the extra revenue it had promised to generate, the hospital failed to report troubling details of a patient's death to government regulators, and four current or former UMC officials alleged mismanagement .
The company is expected to exit the hospital early in 2018. Veritas officials declined to comment through a spokeswoman.
Medical experts said timely assessment and treatment is critical for pregnant women with serious health complaints — and for their babies.
However, Dr. Constance Bohon, an assistant clinical professor of obstetrics and gynecology at the George Washington University School of Medicine, said severe health problems such as morbid obesity and preeclampsia create unusual challenges for obstetricians even under the best of circumstances.
"This is just loaded with so many moving parts," she said.
In an Aug. 7 letter to UMC chief executive Luis Hernandez, the Department of Health cited Ayobo's case and two earlier incidents in the closure of the obstetrics ward.
In one of those cases, a routine blood screening was performed too early on an infant born in February. In the other, a vaginal delivery was performed in November 2016 on a woman with HIV, increasing the risk that her baby would be born with the virus.
The Health Department's investigation of the latter states that although the woman initially refused a Caesarean section, doctors did not follow the proper steps to fully inform her of the risks involved in vaginal delivery.
On Dec. 13, four months after the Health Department's action, UMC's board voted against reopening the nursery and delivery rooms, citing safety concerns and financial pressures.
The permanent loss of obstetric and prenatal services in the part of the District that arguably needs them most has alarmed community activists and maternal-health advocates.
The Health Department's most recent report on infant mortality in D.C., which analyzed data from 2014, found a rate of 12.5 deaths per thousand live births in Ward 8, where Ayobo lived and where UMC is located, compared with 7.6 District-wide and 1.3 in affluent Ward 3, at the other end of the city.
The national rate over the same period was 6 deaths per thousand live births.
Christopher L. Hawthorne, an advisory neighborhood commissioner in Ward 8, said the decision not to reopen the nursery and deliver rooms "would tremendously affect people" in Southeast D.C. "That's one of those services that is a right-now service, that we need on our side of the city," he said.
Four days after Ayobo's death, her cousins once again learned what is at stake.
Phoenix Somesha Carpenter was showing no signs of brain activity, according to Ayobo's family and Phoenix's father, Patrick Carpenter. Her condition was probably a result of insufficient oxygen before and after her mother's death.
They decided, after consulting with doctors, to remove the child from life support.
Peterson dressed Phoenix in a white gown edged with lace, and she and Lewis took turns holding her in her room at Children's National. It was after midnight, Lewis said, and to their surprise, Phoenix began sighing and mewling like a healthy newborn.
"She was breathing. She was smiling. She was making sounds," he said. "Then I saw the blood come out of her nose."